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Erasing the Mark
Laser and Energy-Based Options
"You need a device that
can penetrate deeply, as
deep as the scar goes."
Dr. Waibel recently made a presentation on behalf of the
medical laser company Lumenis (lumenis.com), which has developed the SCAARFX (Synergistic Coagulation and Ablation
for Advanced Resurfacing) mode for its UltraPulse Fractional
CO2 Laser to treat severe lesions, like acne and surgical scars.
The SCAARFX mode is unique because it can penetrate as
deep as 4mm into the dermis.
"Most experts believe you need a device that can penetrate
deeply, as deep as the scar goes. Scars are probably deeper
than we estimate as physicians," Dr. Waibel says. "With
SCAARFX, we can treat a scar anywhere from 100µ to 4,000µ
in depth. Some devices go only as far as 800µ, meaning you
don't even have the option to treat some kinds of scars."
12 July/August 2013 | ACNE & ROSACEA
The results shown are 14 weeks following one treatment with the
ablative fractional CO2 SCAARFX device.
Another beneﬁt, she says, is that "you can really treat scars as
soon as they appear. The sooner you treat the scar, the better."
As for side effects, Dr. Waibel says that physicians must be
careful to avoid making scars worse by using settings that are
too high for a particular skin type or location on the skin.
Potential side effects of ablative laser resurfacing include
itching, swelling and redness in addition to scarring, changes
in skin color and infection.
Vic Narurkar, MD, a San Francisco-based dermatologist
and founder of the Bay Area Laser Institute, is a fan of the
nonablative Fraxel 1550nm laser (Solta Medical, fraxel.com).
"It is highly effective for distensible and nondistensible scars
in all skin types, and adjustments with treatment density can
be performed to address the various severity of scars," he
says. "For very deep bound-down scars, we use a combination
of subcision and/or punch excision followed by the Fraxel
1550nm laser. Spot TCA treatment with 100% TCA can be
used for some icepick scars but care is needed in darker skin,
hence we prefer the use of Fraxel."
Improvements with the Fraxel laser alone range from 50%
to 80% for most patients after a series of three to six treatments, says Dr. Narurkar. "We prefer the nonablative fractional laser over ablative fractional lasers. The ablative fractional
lasers are better suited for photoaging and vertical perioral
and periorbital rhytids."
Other laser options are ideal in certain unique situations.
"For purely erythematous scars, we use a vascular laser such as
the VBeam (Syneron, syneron.com) or KTP 532nm laser and
Starlux Max G IPL (Palomar Medical, palomarmedical.com),"
says Dr. Narurkar. "For PIH from acne scars, we are now using
Lytera, a non-HQ cream, and Retin A micro, followed by Vitalize peels or a Clear and Brilliant permea laser."
Dermal ﬁllers are appropriate in some cases. Dr. Narurkar
uses products such as Juvederm Ulta XC (Allergan, juvederm.
com) and Belotero (Merz Aesthetics, belotero.com) for very
deep scars after laser treatment.
Photo Courtesy of Yuan Hong Li, MD
"Now we mostly use lasers and other energy-based systems.
Fractional lasers and fractional radiofrequency systems seem
to be the best we have in 2013," says Dr. Gold. "We have had
quite a bit of success using the fractional RF technologies for
many scars, no matter what type, since we can vary the depth
of the RF. Fractional lasers can be ablative or nonablative—
the nonablative therapies work over several treatments, from
four to six, and the ablative usually requires one to two."
How successful are the treatments for acne scars? "We never promise complete clearance, but we are seeing improvements of 80% to 90% in some of the patients we are treating,"
says Dr. Gold. "And this is good. We can never make 100%, but
we want our patients to be realistic going into the treatment.
Patients who do well are the ones that understand the limitations we have, which are that we cannot be perfect."
Dr. Waibel is a fan of fractional ablative lasers. She has
published several studies on their use in acne scar treatment.
"They're really a game changer and are emerging almost as a
gold standard," she says.
They're especially useful, she says, because they can reach
deeply into the layers of the skin—700µ to 800µ. "You need a
tool that can reach that deep, and chemical peels just weren't
getting far enough down," she says.
That's not the only beneﬁt to laser treatment for acne scars.
"The other powerful thing about fractional ablative therapy
is that it vaporizes the scar and, over three to six months,
normal-appearing collagen ﬁlls in the hole," she says.
In some cases, ablative lasers need an extra boost to treat
the deepest kinds of acne scars. That's where SCAARFX
comes in.